GW1-2022-08198_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information.
Russell Taylor 14,WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A `t' -a l
b alr5 NC Well Coitaactor Certificationfr. Itificatioa Number 15.OUTER CASING for multi-cased wells ORLINER(If a livable
Hedden Brothers Well Drilling, Inc FROM To DIAMETER I TAICICMS HATERIAL
Company Name
fr. ft
[VNER CASING OR'TQBING feeathermal domd4onnl
2.Well Construction Permit#: t7faa "O{�Jr'(O[�— - "o�oZo� FROM TO ULMETER TinCM%TA5 I %IATBRrAL
LUI all applicable hell construction permits(.e.EX.County,Stag Variance,etc) 0 R. lL In.
3.Well Use(checkwell use): 45 ir. in 188 TF-L s
Water Supply Well: 17.SCREEN H
FROM TO DiAETER SLOTSIZE TMCIGNESS I MATERIAL
Agricultural [31viunicipalitPublic ft ft. in.
Geothermal(Henting/Cooling Supply) OResidential Water Supply(single) ft. ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO �r FTER1 FL I EJIPL�CEaIE\TJIETHOD S 1�tObT7
Non-Water Supply Well: ft. I 20 fL I q„n8 1T I PUMP
Monitoring Recovery ft. ft
Injection Well:
ft. I fL
Aquifer Recharge DGroundwatcr Rcmediation
I9.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery 0-Salinity BarrierFROM To MATERIAL, I EMPLAMI TE.\T 31-MOD
Aquifer Test OStormwater Drainage tt. f tL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.D !G LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) I FROM To I DESCRIPTIO\tcolor.hardne=saillroek nve.gmin sire,am)
rt- I '?rJ rL cis/&sand
4.Date Weli(s)Completed:/o�/� Well M' IJr7fr. ` fL I granite
So.Well Location.
Facility/Owner Name Facility IDS(if applicable) ft. ft. — d
1900 ShoDy— Cone P-d. �G(eka�senee a.98783 ft I ft. I MAY0 2 7027
Physical Address,City.and Zip r-� I ft. I ft.
Jacx',bN cou&) 75 1`7—59-at 21.REhL4RK5
•.Tlii�i v�9I I�i';r�r,'�t Q1it" i
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lat/iong is sufficient) 22.Certification:
350 i6.ai3 tv D830 0&.A47 W 3 7
Jqow
6.Is(are)the wells) Permanent or Temporary Signature of Certified tVcll Contractor Dat
`I�'�+ 8}'signing this Jornr,1 hereby eerlify that r twil(s)eras(were)constructed in accordance
7.Is this it repair to an existing well: n Yes or No with 1SA NCRC 02C.0100 or 1Sd'NCAC 0?C.0300 t:'e/1 Cortstrurtlon Standards and that a
/jthis is a repair,fill out knonm well construction information tdesplain the nature-ofthe copy of this record has been provided to the well owner.
repair under 921 renrarlaseuion or on the back ofrhisjanr. 23.Site diagram or additional well details:
o
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I // SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t3o('5 (ft.) 24s. For AJI Wells: Submit this form within 30 days of completion of well
For ntullip►e irells list all depths ifdderew(erainp/e-3Q200'and 3©100 constriction to the following:
10.Static water level below top of casing: 35 (ft.) Division of water Resources,Information Processing Unit;
Ifwaterlmel is above casing,use"_" 1617.Flail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
i_ above, also submit one copy of this form within 30 days of completion of well
(Le Well conry,table,i method, t��fl, �'j��. construction to the following:
(Le.auger,rotary,cable,direct push,etc.) V
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suooly&Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form %%ithin 30 days of
13b.Disinfection type: Amount: � ld completion of well construction to the county health department of the count;,
where consaucted.
Fonn GW-i North Carolina Department of Emitnnmetnal Qm litg-Division of Watcr iles
ourccs Rcvisvd 2"-'_O16
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